60
as a urologic training model by removing endoloop and extracorporeal knot-tying
procedures, adding didactic material, and clip-applying exercise as well [ 9 ]. BLUS
was designed by the Laparoscopic, Robotic, and New Surgical Technology (LRNST)
Committee, with the renal artery model developed by the University of Minnesota
Center for Research in Education and Simulation Technologies (CREST).
The renal artery module was made from organosilicate materials from CREST’s
human tissue database. Each 6 cm artery, pictured in Fig. 5.7, is filled with artificial
blood and marked with two black lines for clip placement, then attached to a machine
that simulates arterial pulsing. Surgeons were tasked with placing to clips on each
side of the artery and cutting between the marks. Scores were decreased for improper
clip placement, crossing clips, and leaking from the clips. The exercise illustrated
evidence for face, content, concurrent, and convergent validity by Sweet et al. [ 9 ].
A later BLUS study found that all tasks showed evidence for construct validity
when based on skill categories from their demographic survey, but only the peg transfer
and suturing skill tasks earned construct validity when based on established objective
metrics [ 10 ]. This discrepancy in construct validity, or how well a test can distinguish
between skill levels, emphasizes how self- reporting values (as in the demographics
questionnaire researchers presented consented subjects with) may be disappointingly
inaccurate. The authors noted that some of the values reported were simply impossible
(it isn’t possible to do 2 procedures every week while simultaneously reporting 2 pro-
cedures per month). This analysis led them to a larger and even more concerning ques-
tion: if subjects can’t even accurately describe the number of cases they’ve done, will
their reported performance benchmarks be any more reliable?
While the renal artery clipping exercise showed evidence for validity, it is not yet
commercially available and must be assembled by hand. The proposed urology-
specific didactic material is still currently being developed. As of yet, BLUS has yet
to be implemented, but does look promising, and may serve as a model for other lapa-
roscopic specialties to implement their own specific FLS-based training curricula.
Simulation
In order to enable rehearsal of the psychomotor skills unique to laparoscopic sur-
gery, so-called box trainers, which consist of an inanimate physical task, placed
inside an enclosed box with a lighted camera and instruments inserted from outside,
abFig. 5.7 BLUS renal artery clipping exercise before (a) and after (b) clipping
E.I. George et al.